• PATIENT INFORMATION

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status*
  • Format: (000) 000-0000.
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE INFORMATION

  • Is patient covered by additional insurance?
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • ASSIGNMENT AND RELEASE
    I certify that I, and/or my dependent(s), have insurance coverage with       and assign directly to AHS Medical Group all insurance benefits, If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. 

    The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • PHONE NUMBERS

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN CASE OF EMERGENCY, CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • ACCIDENT INFORMATION

  • Is condition due to an accident?*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of accident
  • To whom have you made a report of your accident?
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Frequency:*
  • In the last 6 months, the pain is:*
  • Area of Pain/Numbness/Injury: Please Circle area of concern. *
  • Symptoms*
    Rows
  • Symptoms*
    Rows
  • Allergies (Please list all)*
    Rows

  • History of Present illness

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is it?*
  • Subjective Progression over last 6 months?*
  • Does pain radiate or travel?*

  • Pain and Numbness Scale 0-10

  •
  • What makes pain or numbness better?*
  • What makes the pain worse?*
  • Is the pain:*
  • Have you considered surgery?*
  • Have you had previous treatment or surgery?*
  • Have you had any Nerve testing, EMG?*
  • Any Xray, CT, MRI?*

  • Daily Activity Impairment

    Select the number that indicates how you feel on a daily basis
    0=no difficulties 5=moderate difficulty 10=severe or unable to perform

  • *
    Rows

  • Past Medical Health History

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Blood Thinners*
  • Blood thinners are:
  • Blood Clots*
  • Blood clots in:
  • Vitamin deficiency*
  • Vitamin deficiency:
  • Anesthesia Problems*
  • Anemia*
  • Depression*
  • Anxiety*
  • Arthritis*
  • Sleep Apnea*
  • Epilepsy*
  • Fibromyalgia*
  • Polio*
  • Neuropath*
  • Diabetes Type 1*
  • Diabetes Type 2*
  • Ulcers*
  • Vascular Surgery*
  • Spider Veins*
  • Varicose Veins*
  • Lupus*
  • Heart Disease*
  • High Cholesterol*
  • High Blood Pressure*
  • Chest Pain*
  • Lung Disease*
  • COPD*
  • Emphysema*
  • Thyroid Problems*
  • HIV*
  • Kidney Disease*
  • Liver Disease*
  • GERDS*
  • MRSA*
  • Shingles*
  • Weakness*
  • Plantar Fasciitis*
  • Chemical Exposure*
  • Chemical Exposure:
  • Disc:*
  • Disc:
  • Hernia*
  • Hepatitis*
  • Sciatica: R L Both*
  • Gout*
  • Stroke/ TIA*
  • Chest pain*
  • Hernia:*
  • Lower Back Pain*
  • Spinal Fractures*
  • Spinal stenosis*
  • Spinal arthritis*
  • Degenerative Disc*
  • Fusion:*
  • Joint Replacement*
  • CANCER*
  • Chemotherapy*
  • Radiation*
  • Medication*
  • Pregnant or Breast Feeding*
  • Past Surgical History
    Rows

  • Social History

  • Tobacco*
  • Chewing Tobacco*
  • Alcohol*
  • Recreational Drugs*
  • Exercise*

  • Family History

  • Mother:*
  • Father:*

  • Review of Systems

  • Constitutional

  • Recent Weight*
  • Fever*

  • Skin

  • Discoloration*
  • Pigment Changes*

  • Neurologic

  • Migraines*
  • Headaches*
  • Dizziness*

  • Respiratory

  • Cough*
  • Cough*
  • Pneumonia*
  • Tuberculosis*

  • Gastrointestinal

  • Nausea*
  • Abdominal pain*
  • Constipation*
  • Diarrhea*
  • GI disturbance*

  • Cardiovascular

  • Palpations*
  • Swelling Feet/Ankles*
  • Pounding Heart*
  • Low Blood Pressure*

  • Extremities

  • Cold*
  • Numbness*
  • Tingling*
  • Pain*
  • Medication and/or Supplements
  • Should be Empty: